Acute diarrheal disease is a leading cause of illness globally and is associated with an estimated 1.7 million deaths per year. Among children <5 years of age, diarrheal disease is second only to lower respiratory infection as the most common infectious cause of death. The morbidity from diarrhea also is significant. Recurrent intestinal infections are associated with physical and mental stunting, wasting, micronutrient deficiencies, and malnutrition. In short, diarrheal disease is a driving factor in global morbidity and mortality.
The wide range of clinical manifestations of acute gastrointestinal illnesses is matched by the wide variety of infectious agents involved, including viruses, bacteria, and parasites (Table 128-1). This chapter discusses factors that enable gastrointestinal pathogens to cause disease, reviews host defense mechanisms, and delineates an approach to the evaluation and treatment of patients presenting with acute diarrhea. Individual organisms causing acute gastrointestinal illnesses are discussed in detail in subsequent chapters.
TABLE 128-1Gastrointestinal Pathogens Causing Acute Diarrhea |Favorite Table|Download (.pdf) TABLE 128-1 Gastrointestinal Pathogens Causing Acute Diarrhea
|Mechanism ||Location ||Illness ||Stool Findings ||Examples of Pathogens Involved |
|Noninflammatory (enterotoxin) ||Proximal small bowel ||Watery diarrhea ||No fecal leukocytes; mild or no increase in fecal lactoferrin ||Vibrio cholerae, enterotoxigenic Escherichia coli (LT and/or ST), enteroaggregative E. coli, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus, Aeromonas hydrophila, Plesiomonas shigelloides, rotavirus, norovirus, enteric adenoviruses, Giardia lamblia, Cryptosporidium spp., Cyclospora spp., microsporidia |
|Inflammatory (invasion or cytotoxin) ||Colon or distal small bowel ||Dysentery or inflammatory diarrhea ||Fecal polymorphonuclear leukocytes; substantial increase in fecal lactoferrin ||Shigella spp., Salmonella spp., Campylobacter jejuni, enterohemorrhagic E. coli, enteroinvasive E. coli, Yersinia enterocolitica, Listeria monocytogenes, Vibrio parahaemolyticus, Clostridium difficile, A. hydrophila, P. shigelloides, Entamoeba histolytica, Klebsiella oxytoca |
|Penetrating ||Distal small bowel ||Enteric fever ||Fecal mononuclear leukocytes ||Salmonella Typhi, Y. enterocolitica |
Enteric pathogens have developed a variety of tactics to overcome host defenses. Understanding the virulence factors employed by these organisms is important in the diagnosis and treatment of clinical disease.
The number of microorganisms that must be ingested to cause disease varies considerably from species to species. For Shigella, enterohemorrhagic Escherichia coli, Giardia lamblia, or Entamoeba, as few as 10–100 bacteria or cysts can produce infection, while 105−108 Vibrio cholerae organisms must be ingested to cause disease. The infective dose of Salmonella varies widely, depending on the species, host, and food vehicle. The ability of organisms to overcome host defenses has important implications for transmission; Shigella, enterohemorrhagic E. coli, Entamoeba, and Giardia can spread by person-to-person contact, whereas under some circumstances Salmonella may need to grow in food for several hours before reaching an effective infectious dose.
Many organisms must adhere to the gastrointestinal mucosa as an initial step in the pathogenic process; thus, organisms that can compete with the normal bowel flora and colonize the mucosa have an important advantage in causing disease. Specific cell-surface proteins involved in attachment of bacteria to intestinal cells are ...